London Foundation Certificate

Accredited

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London Foundation Certificate

Counselling and Psychotherapy

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APPLICATION FORM

Please complete clearly, in black ink or on a PC.

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Section 1- Personal/Contact Details

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Please insert/attach a recent passport photo

First name (s): ......

Family name: ......

Gender (M/F): ......

Date of birth: ......

Country of birth: ......

Nationality: ......

Address: ......

...... Postcode: ......

Principle telephone number: ......

Alternate telephone number: ......

eMail address (this should be accessible confidentially and not only during working hours):

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Website, if appropriate: ......

Section 2 - Education

Schools/Colleges/Universities attended since the age of 15:

FromToName of Institution

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Qualifications gained:

DateQualificationSubjectGrade

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Psychotherapy/counselling training (if relevant):

Training institute/college: ......

Course title: ......

Start/end date of course: ......

Theoretical Approach: ......

Qualification gained: ......

Was your previous course accredited? ......

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Section 3 – Psychotherapy, counselling and other work experience

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Current Occupation ......

Have you had any previous experience as a counsellor or psychotherapist?YES/NO

Details of any psychotherapy or counselling work experience: ......

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Are you currently a member of any governing body or counselling organisation?YES/NO

If YES, please give details (e.g. name of organisation and current status)

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Are you currently in personal therapy/counselling?YES/NO

Have you ever been in personal therapy/counselling?YES/NO

If YES to either of the above, please state how many hours you have had: ......

Other relevant work experience (please insert an additional page if you need more space):

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If you have any certified medical condition which may impact on your learning or attendance, please inform us here:

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Section 4 – Personal Statement

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Please write a few words about yourself (no more than 250), explaining why you wish to take this particular foundation course in counselling and psychotherapy. Please address the course requirements, and also tell us anything else you would like us to know about you, which you feel is relevant to this application.

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Section 5 - References

In line with government guidelines, we need to ask whether you have a criminal record: YES/NO

If YES, please provide details: ......

Please provide the name and email address of one professional referee, whom we can contact:

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Section 6 - Declaration

I confirm that the information on this form is correct, to the best of my knowledge.

Signature: ...... Date:......

Please keep a copy for your own records, and submit this application, together with a current CV, to the Course Director, Jean Miller, UKCP reg., either by scanning and emailing to:

or by posting to:

Jean Miller, 40 Grosvenor Road, Muswell Hill, London N10 2DS.

Every submitted course application form is subject to the provisions of the Data Protection Act. For administrative purposes, the names of those accepted on the LFCCP course are usually passed to COSRT in support of COSRT membership and to other counselling organisations in support of the students' placement applications. Please advise us in writing if you wish to withhold permission for us to pass on such details for those purposes. At no time will your details be passed to anyone other than those involved in the training, course administration, placement provision or professional governing bodies. Each student will be placed on email distribution lists dedicated to their student cohort.

Our Data Privacy Policy in full:

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